Healthcare Provider Details

I. General information

NPI: 1710637871
Provider Name (Legal Business Name): LIFE FUSION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MEDICAL DR STE 3
BOUNTIFUL UT
84010-5174
US

IV. Provider business mailing address

242 LEWIS PARK CIR
BOUNTIFUL UT
84010-5742
US

V. Phone/Fax

Practice location:
  • Phone: 801-698-3710
  • Fax: 801-823-0225
Mailing address:
  • Phone: 801-698-3710
  • Fax: 801-823-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TORY HINKLE
Title or Position: CO-FOUNDER
Credential: MD
Phone: 801-698-3710